Since the Australian Health Practitioner Regulation Agency investigation commenced, the GP has agreed to stand down, his patient records have been seized, and a community funding campaign to defend him has started in the organised anti-vaccination community.

Vaccination exemptions have been tighter since the “No Jab, No Pay” legislation came into effect in January 2016. Access to the Child Care Benefit, Child Care Rebate and the Family Tax Benefit Part A end-of-year supplement is now limited to families who vaccinate to the schedule, or have a legitimate medical exemption. Families declaring conscientious objection no longer receive the supplementary payments. While there has been much discussion about the pros and cons of financial incentives, a large number of additional children have been fully vaccinated since the law change.

Many of us who have practised for some time will remember getting many of the vaccine-preventable infections ourselves in childhood, and also treating miserable children with measles, or rotavirus gastroenteritis or Haemophilus influenza type b epiglottitis. Thanks to vaccination – with no change in nutrition, lifestyle or sanitation – these diseases have been controlled. Not to mention, of course, smallpox, polio and tetanus. Most new graduates have never seen many of these conditions.

What, then, makes experienced medical practitioners question the effectiveness and safety of vaccination? We know that they aren’t 100% safe – no aspect of life is, let alone medical treatment. We also know that they aren’t 100% effective – which is why herd immunity is so important.

Anti-vaccination sentiment is quite widespread among some “alternative” health care providers, such as the subluxation-based chiropractors. Medical practitioners, though – and especially GPs – are at the frontline of both childhood infections and vaccination. It takes serious cognitive dissonance to distort the risk–benefit balance against vaccination.

Many people would construct this as a human rights argument: the right to refuse vaccination, and the right to practice medicine according to one’s judgement. In Australia, we retain the right to decline vaccination, although financial incentives may be foregone. Registered providers do not, however, have the automatic right to practice outside the accepted standards of our profession.

For those who want to make extraordinary claims about accepted treatment, extraordinary evidence is required. And yet, it is not the eminent vaccine researchers, paediatricians or infectious disease specialists who are questioning the safety and effectiveness of vaccination. What is it, then, that this small fringe of dissenting doctors think they know, that those with most expertise don’t know?

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.

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Poll

Doctors don't have the automatic right to practice outside accepted standards re vaccination

I was born in 1940 in rural Queensland and as far as I am aware, never received any vaccinations in early childhood. This may have been due in part to isolation and possibly the mistrust engendered by the diphtheria vaccination tragedy in Bundaberg which killed 12 children in 1927.
I contracted the following now preventable infections;
varicella; subsequently zoster and Bell’s palsy with residual facial hemiparesis
pertussis; resulting in bronchopneumonia and bronchiectasis.
rubella; probable hearing loss
measles
mumps- with mumps meningitis and exacerbation of hearing loss.
I was given Tetanus antitoxin to prevent tetanus following a severe infection sustained on a farm.
Furthermore, in primary school, I lost two peers to polio, and another developed trismus but survived.
Health and Hygiene are Public Health issues and there are laws in place to ensure the safety of the population at large.
Vaccination is a Public Health issue, and while I respect the right of an individual to have their opinions, the vaccination deniers should move to some other country where medieval conditions still prevail and avoid endangering the rest of the population through falling herd immunity.

Vaccination is one of the success stories of the 20th century, responsible for the eradication of diseases like smallpox and the almost complete disappearance , at least in countries where available, of child killers like diphtheria and epiglotitis, and other serious, potentially fatal diseases like tetanus and poliomyelitis..

I remember seeing an old black and white photo of parents queuing for many hundreds of metres to get the new polio vaccine for their children in the 1950s.

It is hard to fathom that there are people who oppose vaccination protection, and even harder to fathom that a few doctors hold these views.

Vaccines have to an extent been a victim of their own success–the current generations have not witnessed the epidemics of infectious disease that decimated communities of the past.

I was one of the children in the line when the vaccine arrived in Darwin. My mother and youngest sister had both been quarantined with polio in the 1953 epidemic in Western Australia, so I had no hope of my objections to needles being considered. I also made sure that all my children had every possible childhood vaccination.

I suspect Randal Williams is correct about the current “spectrum bias” – young doctors and parents have grown up without ever having personally suffered, or having seen, many of these conditions.

What I don’t understand is those older practitioners who hold anti-vax views, despite having seen these conditions and the harms they can cause. Is there something about being seen as a maverick, or iconoclast, that appeals to there sense of heroism? Certainly some of these people are elevated to hero status by the anti-vax community.

While herd immunity is important, it is not the reason for the increasingly harsh penalties dished out to those unvaccinated.

The change to punitive measures started with Health Minister Roxon, under Rudd, as a blatant tax grab (or at least, a claimed ‘save’ for the budget) when she conflated the *pertussis* quasi-epidemic with vaccination rates and herd immunity, and used it as justification for taking away family tax benefits.

Pertussis has been lingering, with infection rates higher over the past 10 years, along with persistent deaths, not because of any meaningful change in vaccination numbers, but because pertussis has adapted and 80% of infections are now caused by a strain resistant to the acellular vaccine introduced in the 1990s. It is a world-wide phenomenon. Even if there were 100% immunization for pertussis, and all adults had boosters, the neonates/infants too young to have been fully vaccinated (the at-risk group of concern) will be at the same risk, through persistent, massive reservoir in the population. It ain’t rocket science.

There has been no shown risk of herd immunity itself to other vaccine-covered diseases. Vaccination rates are essentially unchanged, while some vaccines like for varicella have notoriously poor efficacy anyway. Anti-vaxxers only comprise 2-3% of the population, while the rest of those unvaccinated aren’t up to date because of logistical issues like poor access to healthcare, and lack of education on their importance.

So we now have all sorts of punishments to force people to vaccinate, when there has not been any meaningful change in risk to the general population. I.e., there were not worse outcomes before Roxon’s tax grab. More and more requirements have been installed since, along with shunning of the unvaccinated who are not an actual risk to the vaccinated, despite high vaccination rates above those thought to confer herd immunity. The screws have been applied, the stick the chosen method, to coerce the vast majority of those unvaccinated who aren’t even ‘objectors’.

I firmly believe in vaccination. That does not mean I must support punishments and banishment for unvaccinated kids and their families. It’s shocking hearing all the sadistic people who call themselves doctors while barracking for ever-increasing punishments, as though those punishments give any meaningfui public health benefit (i.e., benefit to more than the individual).

Rudolf Pitman – you are not correct about the history of the No Jab No Pay law. The payment that is being withheld incorporates the former Maternity Immunisation Allowance – an incentive payment that was in place prior to re-organisation of the Family Tax Benefit system. Like all targeted welfare payments, one needs to comply with the conditions to received the payment.

It’s correct that Pertussis is difficult to control – neither the vaccination nor the disease confer long-term immunity. We do have good evidence, however, that pertussis immunisation during pregnancy is effective at minimising infection in the newborn – the most vulnerable group. This paper from Lancet 2014 is relevant: Effectiveness of maternal pertussis vaccination in England: an observational study. (http://www.sciencedirect.com/science/article/pii/S0140673614606863)

It’s also not correct that herd immunity has not changed. Outbreaks occur where there are clusters of unvaccinated children – such as North Coast NSW. It’s not the national immunisation rate that is important for outbreaks, but the local rate of immunity.

There is good data to show that the uptake of scheduled immunisation, including catch-ups, has been positively influenced by the targeted payment.

I thought Edward Jenner had proven the necessity of vaccination a couple of centuries ago.His work has saved more lives than anyone else in medicine.John Snow’s observations a close second.Vaccination isn’t perfect,what is,some diseases more difficult to vaccinate against eg the plague and tuberculosis.

I had a patient, a young child, die of Haemophilus meningitis just 6 weeks prior to the release of the HIB vaccine.
My older sister was a very lucky survivor of Meningococcal meningitis at the age of 4, well before any vaccine was available. The 2 other children in the ward with the same illness that week both died.
As a resident at Gosford hospital I saw a full-blown case of Tetanus in a woman who’d never been vaccinated against it. Her back spasms were horrendously painful and she had a marked tachycardia. She required 6 weeks treatment in ICU, paralysed and ventilated. I don’t know if she survived; she was not a young woman.
I also saw children with Epiglottitis whose parents would have been delighted not to see their children suffer such a horrible disease. Certainly the anaesthetists whose dangerous job was to intubate them would have preferred not to have to that responsibility.
In my early years of being a GP I had a patient who’d survived Polio, but whose life had been permanently changed. She always needed crutches and often needed a wheelchair. She couldn’t get around without taxis. She would have loved the opportunity to live a normal life.
Only recently I had a patient who declined immunisations for China. “I’ve been there lots of times without getting anything.” On his next visit he contracted Typhoid fever.
Anti-vaccinators talk about individuals who have had side-effects of immunisations, but I can talk about individuals who suffered the consequences of not having these immunisations.

Well said Dr Ieraci. I also think anti-vax views should be an indication for de-regestering medics with AHPRA. These folks are a danger to the public. What’s the point of a practitioner who doesn’t believe in the science from which all our diagnoses, knowledge and treatments come from?

Aaaargh!
I was reading through Sue’s article and came to the Poll section. I am strongly in favour of vaccination so I voted accordingly. It wasn’t until my vote was recorded that I saw the word “don’t”: “Doctors DON’T have the automatic right to practise. . .”
Please decrease the “Strongly Disagree” by 1 vote and increase the “Strongly agree” total by 1.
I must pay more attention to the article “Why some people get dementia and others don’t”.

I have read and re-read Rudolph Pitman’s reply and he is clearly an anti-vaxxer in sheep’s clothing. In places he is on the brink of blurting out their usual mindless diatribes. Herd immunity is the golden boomerang of Public Health. (How many readers remember that wonderful series on ABC radio “The search for the golden boomerang” in the forties?}. Each day at the appointed time, I would lie on our very shop-soilled feltex carpet with my faithful dog “Tuffy”, to listen to the day’s episode, the same as those of the Argonauts, from our battered radiogram with it’s 78’s turntable. It was in this position (on the floor) that I heard the very first episode of the Goon Show and the very first broadcast of Rock Around the Clock! It was if I was hit with a cattle prodder! But I digress. Not every patient has an identical immune system and, hello, there will those whose response is less than perfect. Other HUGE variables are in the particular manufacturing processes of each batch as well as distribution and storage e.g. how good was Dr x’s old fridge. How good was the vaccinator and in what sort of tissue did the stuff end up etc etc. Some will slip through the net as it were and it is these that the anti-vaxxer morons gleefully pounce on. During the recent flare-up of a particularly virulent strain of flu, I was assailed by several flu-vaccinated people who actually went down with a clinical case of it…proven. Very embarrassing and not easily explained until we now know that the virus had mutated in the not inconsiderable gap between vaccine manufacture and actual injection. That shut them up!
It is particularly poignant for me due to the fact that I had previously lost my father to Sydney flu. I also had the misfortune to be involved in the treatment of a case of full blown tetanus, The attending GP in the country was called to see a woman having unusual, very painful spastic symptoms. He made the diagnosis as he walked into the bedroom…you guessed it – rhisis sardonicus of tetanus. She had trodden on a chop bone in the chook pen! There was a RECENT tragic case of tetanus in an unvaccinated child on the NSW North Coast with the excruciatingly painful tetanic spasms etc. How could the parents look at themselves in the mirror! There are none so blind that will not see. Poor innocent child. Keep up the fight folks!

Not vaccinating your children is exactly the same as not feeding your children – it is child abuse, pure and simple. This has nothing to do with conscientious objection, and we would not accept the argument of someone who said: “My friend’s child choked on some food so we decided not to give any food to our children”.

Our government needs to grow a spine, and not pussyfoot around with measures like cutting a little bit of middle class welfare, but act decisively by removing these neglected children from their abusive parents. Then the anti-vaxxers can keep whatever conscientious objection may have, while the rest of the community has safeguarded these vulnerable children.

I agree that we should be looking at sanctions against health practitioners (doctors, nurses, chiropractors, et al) who actively campaign against and promote non-vaccination in their patient population. If nothing else, they should be forced to relearn the reality and un-learn the pseudo-science of anti-vaccination that they have been spouting. I too am unable to see how a medical practitioner, comprehensively trained in the sciences, is unable to see the proven benefits of vaccination.

Dr Roger BURGESS Radiologist – So I am anti-vaxxer for pointing out the stupidity of the crusade against pertussis through ever-increasing penalties for those who don’t vaccinate? One is an anti-vaxxer if one is generally supportive of the vaccination schedule but takes issue with some (any?) aspect of it? That is the sort of silly ideological nonsense that you’re accusing me of.

My opinion gets shaped by the evidence.

1) It makes no sense to blame ‘clusters’ for this epidemic — the clusters were there when the pertussis rate were still oscillating, before the sustained rise seen throughout much of the developed world. That more cases would be seen within a cluster does not imply they are the *source* of it and would occur not matter the cause. The rise in cases has also been concurrent, with common element of switch to acellular at the same time in the 1990s, whereas any cluster changes were not synchronized. Meanwhile, pertussis is now endemic in the VACCINATED, which again, makes it impossible to get herd immunity and which implies that any loss of herd immunity would be a result, not a cause. Add to that the main strain seen (80%+ now) in the vaccinated has increasingly been pertactin NEGATIVE, which is clearly being driven by the vaccine targetting pertactin, with numbers mostly increasing among the vaccinated.

It’s a simple matter to look up all the research that shows the current pertussis epidemic is most likely a result of the change to acellular rather than issues with herd immunity. Even the CDC infectious diseases unit(!) doesn’t attribute the epidemic to loss of herd immunity when it says: “It is most likely that the change in pertussis vaccines (from whole cell to acellular in the 1990s) along with better diagnostics and increased reporting are driving the resurgence of pertussis throughout the United States.” Stick that quote in Google if you can’t believe it. Is the CDC a bunch of “anti-vaxxers”?

As to the history of forced vaccination — I don’t know what the author is saying, but it is most certainly true that Roxon announced the withdrawing of subsidies to families that didn’t vaccinate, while disingenuously blaming anti-vaxxers for the pertussis epidemic, when even at that time it was known that resistant pertussis was increasingly being seen in the vaccinated, as had already been found both in N. America and confirmed in Melbourne.

It may feel good to blame the 2-3% of anti-vaxxers for all the vaccine woes in the world, but maybe before calling others anti-vaxxers you understand both what theire argument is AND what the research says.

You quote national rates of vaccination, but vaccination rates are not evenly distributed – clusters occur in local populations where immunisation rates are low.

Pertussis is a very difficult disease to control – neither active infection nor immunisation confer long-term immunity. The vaccine is, however, much more effective than no vaccine.

I will repeat: the No Jab No Pay policy, which withholds the benefit that incorporates the previous Maternity Immunisation Allowance, is a public health policy. Why should people who refuse to immunise be given a financial incentive designed to encourage immunisation?